Introduction
1.3 What are theories – and why do we need them?
Much of primary care is characterised by untidiness, uncertainty and many different potential approaches to a single problem. The notion of uncertainty, and the gap between theory and reality, will be recurring themes throughout this book. The academic study of primary care includes the theoretical study of ‘grey areas’ and uncertainty in clinical method. It also includes the use of multiple theoretical perspectives to build up a rich picture of a complex and contested field of study. You can probably begin to see why the contempo- rary academic skills of teamwork, knowledge management, communication and adaptability to change are going to be particularly critical to the study of primary care.
Mrs Perkins has a different model – based centrally around the achievement of empathy through shared experience and active listening. The question for her is not ‘what is the diagnosis?’ but ‘who is this patient and what is he or she going through?’ Note that Mrs Perkins views her work not as doing something to the patient but as being there for the patient. Her work is built around a ‘care’
relationship, not a ‘cure’ relationship, and the mental model for the former is not a rational (scientific) one but an experiential (phenomenological) one (see Section 11.5).20If Mrs Perkins were to do a research study, it might take the form of an in-depth case study, written up as a detailed narrative, of a patient whose illness was an epic struggle for survival or quest for meaning.21
Dr Brown’s model of primary care problems is different again. Like Dr Begum, he is interested in influencing the course of the illness, but his ideas about treatment are not primarily biomedical. He uses the word ‘improvise’ – a term more frequently used in relation to jazz music or unscripted theatre.
This suggests that his mental model is based on the view of general practice as an art – where the demonstration of a bit of priestly authority and mystical divination might just help the healing process. The conceptual world of artistic improvisation has little place for ‘causes’ and ‘effects’, but has much to do with the performative relationship between the ‘actor’ and his or her ‘audience’, the roles they assume and the games they play. Dr Brown might even take a psychodynamic model of his work – the notion that in general practice, trivial illness is the vehicle through which painful subconscious (emotional) issues are brought for discussion (the so-called hidden agenda – see Section 6.3).22If Dr Brown were to conduct a research study, it might be a series of reflective discussions between him and his fellow GPs, in which they work through a series of challenging patients and how they attempt to use their professional position (what Balint called ‘the doctor as the drug’– see Section 6.3) to promote emotional (and thereby symptomatic) healing in their patients.22
If you have a conventional hospital-based medical training, you will almost certainly feel most comfortable with the rational, scientific model. If you come from a nursing background, the ‘care’ model might make more sense to you, because much of your undergraduate training would have been based on it (and because much of your work is to do with caring). However, nursing curricula throughout the world vary considerably, and scientific models are increasingly privileged (perhaps reflecting the emergence of the extended role of the nurse in diagnosis, treatment and so on). If you are a British GP, or come from a comparable health care system (such as the Netherlands or New Zealand), you may well be most comfortable with an ‘artistic’ model of general practice and/or with models that consider subconscious, as well as conscious, influences on behaviour. Which model is correct? Think about this for a little before you read on.
If you believe that any one model is the ‘correct’ way to conceptualise ev- ery problem you encounter in primary health care, you have probably not seen very many real-life problems or listened to many people from other professional (and lay) backgrounds. You have probably also not understood Section 1.2 about the multiple underpinning disciplines of primary care! But
if you are an experienced generalist, and especially if you work a lot in multi- disciplinary teams, you will almost certainly know that different conceptual models help us with different sorts of problems – and allow us to have multi- ple ‘takes’ on the same problem. A rational, ‘evidence-based’ model helps us when the problem can be couched in the taxonomy of a specific disease (or a differential diagnosis), whereas the ‘improvisation’ model might become dom- inant when the problem is best expressed as ‘Mrs Jones making yet another appointment after all those negative tests’.
Different primary disciplines are generally based on different conceptual models, though most of the hospital-based medical disciplines share a com- mon biomedical model (in which problems can be analysed at different levels including the molecule, the cell, the organ and so on). There are many other conceptual models relevant to primary care that I have not yet mentioned. If you work in a managerial or executive role, your mental model of primary care is probably one of a complex organisation and you will see problems in terms of appropriate skill mix, effective teamwork, efficient project management and so on. You will have a natural tendency to analyse problems at the level of the team (e.g. particular project groups). And if you work in social services, you are more likely to view problems in terms of the social structures, norms and relationships that produce particular behaviours – that is, your concep- tual model will be the social system and your unit of analysis will be the social group (e.g. teenage mothers).
Take another look at Table 1.4, which illustrates the diversity and scope of academic primary care. You will probably return to it (and perhaps add to it) when you begin to conceptualise and theorise about the primary care problems you meet in your own practice. Once you begin to do that, even if you do not find any easy answers, you can call yourself an academic primary care practitioner.
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CHAPTER 2